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American College of Cardiology, Puerto Rico Chapter

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Pharmacotherapy for Chronic Stable Angina Pectoris Pharmacotherapy to Prevent MI and Death Pharmacotherapy to Reduce Ischemia and Relieve Symptoms ... – PowerPoint PPT presentation

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Title: American College of Cardiology, Puerto Rico Chapter


1
American College of Cardiology, Puerto Rico
Chapter
Guidelines Applied to Practice (GAP)

2
American College of Cardiology Puerto Rico
Chapter
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • February 6, 2006
  • Eduardo J. Viruet M.D., F.A.C.C.

3
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • 68-year-old man with history of dyslipidemia,
    arterial hypertension and Diabetes Mellitus II
  • Chest discomfort associated to strenuous physical
    activity
  • LDL levels 170 mg/dl
  • What is the adequate initial therapy?
  • What preventive measures should be taken ?

4
Pharmacotherapy for ChronicStable Angina Pectoris
  • Pharmacotherapy to Prevent MI and Death
  • Pharmacotherapy to Reduce Ischemia and Relieve
    Symptoms

5
Pharmacotherapy for ChronicStable Angina Pectoris
  • Therapy to Prevent MI and Death
  • Aspirin
  • Beta Blockers
  • Statins
  • ACE inhibitors

6
Pharmacotherapy for ChronicStable Angina Pectoris
  • Therapy to Reduce Ischemia and Relieve Symptoms
  • Nitrates
  • Beta Blockers
  • Calcium channel Blockers

7
Pharmacotherapy for ChronicStable Angina Pectoris
  • ABCDE Formula
  • ASA and antianginal
  • Beta-blockers and blood pressure
  • Cholesterol and cigarettes
  • Diet and diabetes mellitus
  • Education and exercise

8
Cigarette Smoking Recommendations
Goal Complete Cessation and No Exposure to
Environmental Tobacco Smoke
  • Ask about tobacco use status at every visit.
  • Advise every tobacco user to quit.
  • Assess the tobacco users willingness to quit.
  • Assist by counseling and developing a plan for
    quitting.
  • Arrange follow-up, referral to special programs,
    or pharmacotherapy (including nicotine
    replacement and bupropion.
  • Urge avoidance of exposure to environmental
    tobacco smoke at work and home.

9
Blood Pressure Control Recommendations
Goal lt140/90 mm Hg or lt130/80 if diabetes or
chronic kidney disease
Blood pressure 120/80 mm Hg or greater
Initiate or maintain lifestyle modification
weight control, increased physical activity,
alcohol moderation, sodium reduction, and
increased consumption of fresh fruits vegetables
and low fat dairy products
  • Blood pressure 140/90 mm Hg or greater (or 130/80
    or greater for chronic kidney disease or
    diabetes)
  • As tolerated, add blood pressure medication,
    treating initially with beta blockers and/or ACE
    inhibitors with addition of other drugs such as
    thiazides as needed to achieve goal blood
    pressure

10
Physical Activity Recommendations
Goal 30 minutes 7 days/week, minimum 5 days/week
  • Assess risk with a physical activity history
    and/or an exercise test, to guide prescription
  • Encourage 30 to 60 minutes of moderate intensity
    aerobic activity such as brisk walking, on most,
    preferably all, days of the week, supplemented by
    an increase in daily lifestyle activities
  • Advise medically supervised programs for
    high-risk patients (e.g. recent acute coronary
    syndrome or revascularization, HF)

11
Lipid Management Goal
LDL-C should be less than 100 mg/dL Further
reduction to LDL-C to lt 70 mg/dL is reasonable
If TG gt200 mg/dL, non-HDL-C should be lt 130
mg/dL
Non-HDL-C total cholesterol minus HDL-C
12
Lipid Management Goals NCEP
Risk Category LDL-C and non-HDL-C Goal Initiate TLC Consider Drug Therapy
High risk CHD or CHD risk equivalents (10-year risk gt20) and lt100 mg/dL if TG gt 200 mg/dL, non-HDL-C should be lt 130 mg/dL ?100 mg/dL gt100 mg/dL (lt100 mg/dL consider drug options)
Very high risk ACS or established CHD plus multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors lt70 mg/dL, non-HDL-C lt 100 mg/dL All patients gt100 mg/dL (lt100 mg/dL consider drug options)
ATPAdult Treatment Panel, CHDCoronary heart
disease, LDL-CLow-density lipoprotein
cholesterol, TLCTherapeutic lifestyle changes
Grundy, S. et al. Circulation 2004110227-39.
13
Lipid Management Recommendations
Assess fasting lipid profile in all patients, and
within 24 hours of hospitalization for those with
an acute event. For patients hospitalized,
initiate lipid-lowering medication as recommended
below prior to discharge according to the
following schedule
If baseline LDL-C gt 100 mg/dL, initiate
LDL-lowering drug therapy If on-treatment LDL-C gt
100 mg/dL, intensify LDL-lowering drug therapy
(may require LDL lowering drug combination) If
baseline is LDL-C 70 to 100 mg/dL, it is
reasonable to treat to LDL lt 70 mg/dL
When LDL lowering medications are used, obtain at
least a 30-40 reduction in LDL-C levels.
14
Lipid Management Recommendations
If TG are 200-499 mg/dL, non-HDL-C should be lt
130 mg/dL Further reduction of non-HDL to lt 100
mg/dL is reasonable Therapeutic options to
reduce non-HDL-C More intense LDL-C lowering
therapy I (B) or Niacin (after LDL-C lowering
therapy) IIa (B) or Fibrate (after LDL-C lowering
therapy) IIa (B) If TG are gt 500 mg/dL,
therapeutic options to prevent pancreatitis are
fibrate or niacin before LDL lowering therapy
and treat LDL-C to goal after TG-lowering
therapy. Achieve non-HDL-C lt 130 mg/dL, if
possible
15
Weight Management Recommendations
Goal BMI 18.5 to 24.9 kg/m2 Waist Circumference
Men lt 40 inches Women lt 35 inches
  • Assess BMI and/or waist circumference on each
    visit and consistently encourage weight
    maintenance/
  • reduction through an appropriate balance of
    physical activity, caloric intake, and formal
    behavioral programs when indicated.
  • If waist circumference (measured at the iliac
    crest) gt35 inches in women and gt40 inches in men
    initiate lifestyle changes and consider treatment
    strategies for metabolic syndrome as indicated.
  • The initial goal of weight loss therapy should be
    to reduce body weight by approximately 10 percent
    from baseline. With success, further weight loss
    can be attempted if indicated.

BMI is calculated as the weight in kilograms
divided by the body surface area in meters2.
Overweight state is defined by BMI25-30 kg/m2.
Obesity is defined by a BMI gt30 kg/m2.
16
Diabetes Mellitus Recommendations
Goal Hb A1c lt 7
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (lt7). Vigorous modification of
other risk factors (e.g., physical activity,
weight management, blood pressure control, and
cholesterol management as recommended).
Coordinate diabetic care with patients primary
care physician or endocrinologist. )
HbA1c Glycosylated hemoglobin
17
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • 65-year-old woman with history of Diabetes
    Mellitus II, and arterial hypertension
  • Chest discomfort and fatigue at minimal physical
    activity on optimal medical therapy
  • Patients also complains of leg swelling, 2
    pillows orthopnea, dyspnea on exercise
  • What will be the adequate diagnostic test?

18
Invasive Testing in Chronic Stable Angina
  • Recommendations for Coronary Angiography
  • Patients with disabling (Canadian Cardiovascular
  • Society CCS classes III and IV) chronic
    stable angina despite medical therapy
  • Patients with high-risk criteria on clinical
    assessment or noninvasive testing regardless of
    anginal severity

19
Invasive Testing in Chronic Stable Angina
  • Recommendations for Coronary Angiography
  • Patients with angina who have survived sudden
    cardiac death or serious ventricular arrhythmia
  • Patients with angina and symptoms and signs of
    congestive heart failure

20
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • 64 years old male with history of arterial
    hypertension and chronic smoking
  • Complaining of chest pain with moderate physical
    activity
  • Baseline EKG shows CLBBB
  • What will be the adequate diagnostic test?

21
Cardiac Stress Imaging in Patients With Chronic
Stable Angina
  • Abnormal rest ECG or are using digoxin
  • LBBB or electronically paced ventricular rhythm
  • Prior revascularization (either PCI or CABG)
    pre-excitation
  • Wolff-Parkinson-White syndrome
  • or more than 1 mm of rest ST depression

22
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • 48 years old male with history of arterial
    hypertension and dyslipidemia
  • Family history of premature CAD
  • Complains of neck and left shoulder pain with
    moderate exercise

23
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • EKG with inverted T waves in anterior leads
  • Exercise stress test with myocardial perfusion
    showed stress induced large anterior ischemic
    defect
  • What is the next step of therapy?

24
High-risk criteria on noninvasive testing
  • Severe resting left ventricular dysfunction (LVEF
    lt 35)
  • High-risk treadmill score (score -11)
  • Severe exercise left ventricular dysfunction
  • (exercise LVEF lt35)

25
High-risk criteria on noninvasive testing
  • Stress-induced large perfusion defect
  • Stress-induced multiple perfusion defects of
    moderate size
  • Large, fixed perfusion defect with LV dilation or
    increased lung uptake (thallium-201)

26
High-risk criteria on noninvasive testing
  • Stress-induced moderate perfusion defect with LV
    dilation or increased lung uptake (thallium-201)
  • Echocardiographic wall motion abnormality
    (involving greater than two segments) developing
    at low dose of dobutamine (10 mg/kg/min) or at a
    low heart rate (lt120 beats/min)
  • Stress echocardiographic evidence of extensive
    ischemia

27
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
  • 68 years old female with history of Diabetes
    Mellitus II and dyslipidemia
  • History of heart attack in the past
  • EKG shows inferior Q waves
  • Asymptomatic at this moment
  • What is the next step of therapy?

28
Pharmacotherapy to Prevent MI and Death in
Asymptomatic Patients
  • Aspirin in the absence of contraindication in
    patients with prior MI
  • Beta blockers as initial therapy in the absence
    of contraindications in patients with prior MI

29
Pharmacotherapy to Prevent MI and Death in
Asymptomatic Patients
  • Low-density lipoprotein-lowering therapy in
    patients with documented CAD and LDL cholesterol
    greater than 130 mg/dL, with a target LDL of less
    than 100 mg/dL
  • ACE inhibitor in patients with CAD1 who also have
    diabetes and/or systolic dysfunction

30
American College of Cardiology, Puerto Rico
Chapter
Guidelines Applied to Practice (GAP)

31
American College of Cardiology Puerto Rico
Chapter
GAP
Casos Clínicos
  • San Juan Intercontinental Febrero 6 Eduardo J.
    Viruet MD
  • Casa del Médico, Mayaguez Febrero 7 Francisco
    Jaume MD
  • Casa del Médico, Ponce Febrero 8 Nélida
    González MD
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